Tuesday, 31 January 2017

From the Pulse

GPs set to take half a million COPD patients off steroid inhalers

GPs are being urged to review all their patients with COPD who are taking inhaled steroids in light of new treatment guidelines, with UK experts estimating that as many as half a million patients who are currently prescribed the inhalers should be taken off them.

Under the new guidelines, from the international Global Initiative for Chronic Obstructive Lung Disease (GOLD) network, GPs should avoid starting patients on inhaled corticosteroid (ICS) therapy unless they have ongoing exacerbations that cannot be controlled with long-acting bronchodilator medications.
This marks a significant shift from previous guidelines, including the NICE guidance on COPD, which advise use of ICS inhalers at an earlier stage, and simply on the basis of poor lung function, experts said.

GOLD board member Professor David Halpin, a consultant respiratory physician at the Royal Devon and Exeter Hospital and former chair of the NICE COPD guidelines, told Pulse this means GPs should review patients at the next opportunity – and that as many as half a million currently on ICS therapy should come off the inhalers.

Professor Halpin said: ‘Studies have shown that up to 40% of patients with COPD are over-treated with ICS, and given the total number of people with COPD a figure of half a million over-treated is a reasonable estimate.’

The changes in treatment recommendations come after publication of a raft of studies finding ICS therapy is less effective and more harmful than previously thought, with side effects such as pneumonia outweighing any benefit for many patients.

GPs in some areas have already come under pressure to take patients off steroids under local cost-cutting measures, but Professor Halpin said these had made only a small impact so far and that GPs should start following the latest GOLD advice because the NICE guidance is now seven years out of date. NICE is currently in the process of updating its recommendations but it is thought the final guidelines will not be available until 2018.

Professor Halpin said: ‘It could potentially be confusing for GPs, but the last NICE update was published in 2010 based on 2009 evidence – that is now seven years out of date, and there have been a lot more studies, so until more up to date NICE guidance is available really people should be looking at the more contemporary guidance.’

He added: ‘At the annual review it would be worth identifying people on inhaled steroids, looking at their exacerbation history and deciding whether there is an indication to continue them and if there isn’t, consider withdrawing it in a controlled manner.’

However, GP respiratory experts cautioned that the decision to stop steroid therapy requires very careful assessment – in particular to check for overlapping asthma.

Dr Mark Levy, GPSI in respiratory medicine in North West London, said that while he agreed that the GOLD approach reflected the best evidence-based approach, 'there should be a “health warning” with reducing or stopping inhaled steroids, making 100% sure the person doesn’t have mixed disease with asthma before doing so'.

There are also concerns that GPs still do not have adequate access to the key non-pharmacological alternatives of pulmonary rehabilitation and stop smoking support.

Dr Noel Baxter, chair of the Primary Care Respiratory Society, said the new advice ‘reflects a direction of travel that has been present for a few years now in the UK’ but warned the GOLD guidance ‘is a very long’ and ‘most GPs won’t have time to digest it’.

Dr Baxter said: ‘Locally I would hope COPD interested respiratory specialists and generalists will come together to make a concise and GP relevant guideline using what we now have from GOLD/NICE and our UK respiratory societies.'

Sunday, 29 January 2017

Evidence of Alzheimer's in patients with Lewy body disease tracks with course of dementia

Date:

January 5, 2017

Source:

Perelman School of Medicine at the University of Pennsylvania

Summary:

Patients who had a diagnosis of Parkinson's disease with dementia or dementia with Lewy bodies and had higher levels of Alzheimer's disease pathology in their donated post-mortem brains also had more severe symptoms of these Lewy body diseases during their lives, compared to those whose brains had less AD pathology.

FULL STORY

High magnification photomicrographs of a tau tangle (left) and an alpha-synuclein Lewy body (right).

Credit: Perelman School of Medicine, University of Pennsylvania

High magnification photomicrographs of a tau tangle (left) and an alpha-synuclein Lewy body (right).

Patients who had a diagnosis of Parkinson's disease (PD) with dementia (PDD) or dementia with Lewy bodies (DLB) and had higher levels of Alzheimer's disease (AD) pathology in their donated post-mortem brains also had more severe symptoms of these Lewy body diseases (LBD) during their lives, compared to those whose brains had less AD pathology, according to research from the Perelman School of Medicine at the University of Pennsylvania.

In particular, the degree of abnormal tau protein aggregations, indicative of AD, most strongly matched the clinical course of the LBD patients who showed evidence of dementia prior to their deaths, the team reports in The Lancet Neurology

First Online, ahead of the January print edition.

The team used post-mortem brain tissue donated by 213 patients with LBD and associated dementia, which was confirmed during autopsies to have alpha-synuclein pathology. They paired the tissue analysis with the patients' detailed medical records.

LBD is a family of related brain disorders made up of the clinical syndromes of PD, without or with dementia or DLB. LBD is associated with clumps of misshapened alpha-synuclein proteins. On the other hand, AD pathology is made up of clusters of the protein beta-amyloid called plaques and twisted strands of the protein tau, called tangles. Patients with LBD may have varying amounts of AD pathology, in addition to alpha-synuclein pathology.

Treatments directed at tau and amyloid-beta proteins are currently being tested in patients with Alzheimer's disease. This study could help in selecting appropriate patients for trials of emerging therapies targeting these proteins singly or in combination with emerging therapies targeting alpha-synuclein protein in LBD.

The study, led by David Irwin, MD, an assistant professor of Neurology at Penn and an attending cognitive neurologist in the Penn Frontotemporal Degeneration Center and the Center for Neurodegenerative Disease Research, suggests that Lewy body pathology is the primary driver of disease seen in the patients; whereas, AD pathology has an impact on the overall course of disease.

"We are excited with the results of this collaborative study that points to tau as a major correlate of dementia since therapies targeting tau in AD are advancing and they could be as relevant to AD as to LBD with co-occurring AD-like tau pathology." Irwin said. "In addition, clinical trials for other synuclein-related brain disorders may be improved by taking into account biomarkers of AD pathology."

"This study is important for many reasons, not the least of which it illustrates the power of research that harnesses the resources of all of these collaborating centers," said senior author John Q. Trojanowski, MD, PhD, director of the Penn ADCC and Udall Center and a professor of Pathology and Laboratory Medicine.

None of the LBD patients had a clinical diagnosis of AD, but their post-mortem brain tissue revealed varying amounts of AD neuropathology. Post-mortem analysis of five brain regions per patient showed that they fell into one of four categories of AD pathology: 23 percent negligible or no AD, 26 percent had low-level, 21 percent intermediate, and 30 percent had high-level.

Increasing severity of AD pathology correlated with a shortened time from motor symptoms to the onset of dementia and death, with the most significant trends seen in the intermediate- and high-level AD groups compared to the low-level and no AD groups. Tau pathology, in particular, was the strongest predictor of a shorter time to dementia and death. AD pathology was also higher in patients who were older at the time of onset of motor symptoms and dementia.

"We found that patients with a higher burden of Alzheimer's pathology also had a higher burden of alpha-synuclein pathology in their brain," Irwin said. "From this, we inferred a potential synergism between the deleterious processes in AD and DLB." Trojanowski added there is experimental evidence for synergies between these pathologies in animal models.

The team also found that two relevant genetic variants in sequences of the patients' DNA samples correlated with the amount of AD pathology.

The frequency of a genetic variant in a gene coding for a protein involved in cholesterol metabolism (APOE, the most common risk factor for AD) was more frequent in patients who were in the intermediate or high AD pathology group compared to those in the low-level or no AD group. Interestingly, a variation in the gene for the protein GBA (a risk factor for LBD) was more frequent in patients without significant AD pathology. This gene is associated with LBD overall but not the subgroup with AD pathology.

In the brain, the enzyme GBA normally aids in the breakdown of worn out and misshapened proteins, such as alpha-synuclein. Together these findings suggest that genetic risk factors could influence the amount of AD pathology in LBD. Further understanding of the relationships between genetic risk factors and AD and alpha-synuclein pathology will help improve treatments for these disorders.

Thursday, 26 January 2017

We have a brilliant NHS and police, fire services etc, but along with this we have another service, which is voluntary, and hardly gets a mention at times.

This is our carers, who never get mentioned largley because the media and the Government don't really care, until it comes to award ceremonies, then they turn up and praise those involved. But that's in front of television cameras etc.

We hear about these carers who do wonderful jobs around the world, but many of these have their own individual health problems, which are largely ignored

These people from young children, to the elderly, do a brilliant job, mostly without any support what so ever from the social services or the Governments

These people save Governments millions of pounds each year, and hardly get as much as a thank you let alone payments for their role.

Once a carer is retired, they lose their benefits altogether, even though they are still doing the same caring role, and that to me is disgusting

Many years ago my wife had a serious road accident, after which she had to fight for her life, and then endured over three years of having umteen operations in hospital, where they did their best to save her life, and then rebuilt her leg and foot, which were close to being severed.

There were times when I thought we had lost her, and that was hard, because I got so little sleep, due to worrying about what was to come.

During that time, I looked after the children, while keeping my job going, and fitted in hospital visits, which in many cases were after patient visiting hours, but that hospital cared, and supported us in any way they could.

I admit that my wife wasn't with it most of the time, due to all of the pain killers etc, but I needed to go, as did the children. But during that time, the Sister and nursing staff looked after us all especially the children, and over time we all became firm friends.

During this time our 8 year-old daughter and 6 year old son, kept me going, because I was permanently shattered, and without them I would have been in a mess

Now the roles have reversed and Janice is my carer, and without her I would be lost.

But she hardly ever complains about her leg, which still causes a lot of problems, she just accepts it.

One of my granddaughters has Asbergers, and life can be difficult for those around her.

But around me she is very caring, and walks away when she is going to have a melt down. Other times she is one of the most protective and caring young girls I could ever meet

She understands when I am struggling, although she can be a little over powering at times, her heart is in the right place.

My daughter is her carer, and there are times when I feel for her, because seeing these meltdowns and hearing what goes on can be frightening, if you are not expecting it.

But it's amazing how this young girl puts others first, even though she has her own problems
The other day their neighbour got flooded when a water main burst outside the house at 5am.

Yet this 11 year old young girl asked her mum, if she could make the firemen a cup of tea. This brought me to tears, because it proves she trys to think of others at times.

Yes she can cause problems when she is stressed, hungry or tired, but otherwise she is lovely to be with,

So these days I get really annoyed by the Governments attitude towards carers, because they seem to have little or no respect for them, even though they are doing a brilliant job on their own

What is more, this Government should be doing more to support these carers rather than cutting services to the bare bone, while wasting money on unneeded projects.

However it's not just this Government, the last Labour Government under Mr Blair was exactly the same, uncaring

PLEASE, remember Carers come in all ages, and in many cases have their own individual health problems, "BUT THEY NEVER STOP CARING"

Caring is a 24 hour role, 7 days a week, and it takes its tole on our carers, so please think about them, and respect them

Wednesday, 25 January 2017

It's been a rough week all round, and I am pleased it's over with now.

I found that I struggled with many things including basic cooking, apart from the microwave food, and that was hard to accept.

I now realise that I am restricted in what I am able to do on my own, so I may have to think carefully , next time my wife needs to go away for a few days

Even doing simple things like bacon and eggs, scrambled eggs and omelette were a nightmare. It all looked like some war zone

I remember turning the scrambled eggs over in the glass dish, and it all stayed firmly in the dish, and did not move. I thought it was there to stay, but I managed to get it out.

After years of doing this on my own, I was a little shocked at how things turned out.
I used to, love cooking, but realise that it's a no go area these days.

But I guess it's because I cannot plan things out, and time them as I used to

Still life goes on, and the boss is back home again, so the food will not look like a war zone anymore.

We saw a lovely cruise in the papers today, going up the Norwegian Fiords, something we have wanted to do, while I am still able to do it.

But we then realised that we cannot plan that far, because I am still waiting to hear from the Respiratory Consultant.

My wife rang the consultants secretary to find out when I would see the consultant next, but she was unaware that all of the tests had been completed, but is now arranging the next appointment which is good.

Up until now, the research in to vascular cognitive impairment (VCI) has been relatively uncommon and insufficient.

Insufficiency has affected the prevalence estimates, clinical diagnosis rates and treatment of VCI.

The new study provides guidelines for clearer diagnosis and also to simplify the eligibility for people to take part in specific research studies on VCI.

New guidelines that will help to progress research into vascular cognitive impairment (VCI) have been developed.

New Guidelines for Improving Research into Vascular Dementia

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The study which brought together the views of over 150 researchers in 27 countries was led by academics at the University of Bristol.

‘The new guidelines was designed as a means to overcome the historical barriers and to promote significant progress for research into vascular cognitive impairment (VCI).’

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So far, the research on VCI have been relatively less common than other types of dementia and cognitive impairment. Though numerous diagnostic criteria, from previous research, have tried to trace the differences in clinical manifestations and diagnosis of vascular cognitive impairment (VCI), none have been universally accepted. These criteria have not been readily comparable, impacting the clinical diagnosis rates, prevalence estimates, research, and treatment.Vascular Cognitive Impairment-(VCI) VCI refers to a decline in mental abilities, such as memory, thinking and planning, caused by problems that reduce or block the blood supply to the brain. This can deprive the brain cells of vital nutrients and oxygen. VCI maybe mild or severe depending on the symptoms. The milder form is referred to as mild cognitive impairment. The more severe form of VCI is vascular dementia. VCI is the second most common cause of dementia and gradual memory loss after Alzheimer's disease and there is no cure for either. Vascular dementia is a common form of dementia that is estimated to affect more than 135,000 people in the UK. It contributes to the largest cause of death in England and Wales according to recent reports. Early warning signs of vascular dementia including slowness of thought, difficulty with planning, trouble with language, problems with attention and concentration, mood or behavioral changes.Project The Bristol team, led by Pat Kehoe, Gestetner Professor of Translational Dementia Research and Joint Head of the Dementia Research Group in the School of Clinical Sciences, invited researchers from around the world to participate in a project called the Vascular Impairment of Cognition Classification Consensus Study (VICCCS), which is funded by the Alzheimer's Society. Professor Pat Kehoe, Chief Investigator for the study, said "It may seem somewhat simplistic to some people that this study has been to get people to agree on how to view and name conditions that affects as many as 100,000 people in the UK alone." "However, more than 20 years of research has been significantly hampered because numerous studies looked at this complicated group of related conditions in a large number of ways and under numerous different names. This has made the interpretation of any findings with other studies extremely difficult. For the field to move forward, and for us to successfully test potential therapies, there is a need for much greater clarity so that studies can be designed appropriately and meet with the latest requirements from regulatory bodies." Kehoe adds. The project made use of an online consensus-building technique that uses recurring surveys, known as the Delphi method. The study was conducted in two parts and identified and addressed the issues from the last two decades that have obstructed the progression of VCI research. These surveys addressed issues and came up with consensus agreements that involved six phases of surveys over approximately two. The issues addressed were:

what should be the guiding principles in defining a modern and workable concept of VCI .

how the diagnosis of these conditions can be made in a more standardized way across the world.

Dr Olivia Skrobot, Research Associate in the School of Clinical Sciences, who coordinated the study, added "This study was designed as a means to overcome the historical barriers to advance this area of research. The involvement of so many international researchers will, we hope, promote a new level of collaboration and togetherness and encourage significant progress for VCI research." Dr Doug Brown, Director of Research and Development at Alzheimer's Society said, "Research relies on collaboration between experts in order to pool knowledge to further our understanding of the causes of health conditions and how to treat them. This research will allow us to work from the same understanding and criteria which will significantly speed up research in this vital area."Conclusion The paper, published in Alzheimer's & Dementia: The Journal of the Alzheimer's Association, describes the results of the first part of the VICCCS project. The aim of this part of the study is to provide guidelines for clearer diagnosis and also to simplify the eligibility for people to take part in specific research studies on VCI. The second part of the project which deals with challenges around diagnostic approaches and lack of standardisation, is being prepared for publication. As dementia is now the biggest killer in the UK, the researchers need to bring the much-needed help to people with this condition as quickly as possible.References